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Trauma team leader Chris Hicks walks us through his step by step process of managing patients with penetrating chest trauma.
Great segment guys, thanks. What about performing an ED thoracotomy at a non-trauma center? You guys touched on this a little, but wanted to know your thoughts on cracking the chest if you dont have a trauma surgeon at your shop. Does it all depend on local protocols? If your patient fits into that 30% that is salvageable can you transport your pt with an open chest to the nearest level 1 trauma center?
Hi Sean, here is Dr. Hick's reply...if you have a potentially survivable patient (isolated stab to chest, VSA < 10 absolutely fits this category), and you have reasonable access to a trauma centre by way of inter-facility transfer, then the answer absolutely YES. closing an anterior cardiac wound (sutures, staples, foley) and resuscitating will often produce a very stable patient.
points to ponder though:
1. what's reasonable access? I use the LensCrafters rule -- transfer in about an hour (probably not practical if transport times well in excess of that)
2. the ideal incision: give yourself the best shot, the best exposure -- make a clamshell your initial approach; it's probably the ideal technique for the EP who does this infrequently
3. after ROSC -- leave in bilateral chest tubes, close skin with staples, provide adequate sedation/analgesia, don't forget to reverse any single-lung ventilation you've been doing to facilitate exposure
I know there's a lot more to the discussion, and you can't just up and do this in a ED or with a team who isn't familiar with the procedure. but in the end I think the patient-centered approach in young people with survivable injuries this is the right thing to do, and we need to build systems and understanding, including trauma and non-trauma hospitals, to facilitate that.
Thanks Dr Hicks. What are you thoughts about the approach to a thoracotomy for a non-surgeon ? Left lateral or clamshell for all ?It seems to me that a clamshell, while obviously "dramatic" and a large incision, would give a provider who is probably very unfamiliar with the bloody mess and anatomy, the best chance of quickly identifying the heart and pericardium, and doing a pericardotomy and hole repair. Yet I feel with this approach, the shared mental model and team preparation is EVEN MORE important, as it will be a big mental hurdle for some to overcome and to commit too.Thanks.
Here is the reply from Dr Hicks...
agree 100%. we are not thoracic surgeons -- why operate in a hole? the clamshell is the ideal incision for the non-trauma surgeon.
also agree that you can't just show up to work tomorrow and do a clamshell; you'll probably get letters if you do. building understanding and relationships with surgeons and shared mental models with your team is as important as the procedure itself.
I was hoping for more deciding factors to do, or not do, EDT at a non trauma hospital.... transfer times vs. surgical help available vs....?
What you do matters.